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VCU Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University VCU Division of Cardiothoracic Surgery

VCU Division of Cardiothoracic Surgery

Thoracic aortic disease program

Aortic Surgery

The Thoracic Aortic Surgery Program at VCUMC offers leading surgical care for both elective and emergent aortic procedures. Our team is also involved in research to identify new treatment options that can enhance the quality of life for patients.

Surgery on the aorta has similarities to open-heart surgery. Specifics as to the size and location of the incision, the use of the heart-lung machine and other techniques vary depending on the type of aortic surgery being performed.

When a portion of diseased aorta needs to be removed through surgery the procedure is called aortic resection. A synthetic graft made of Dacron® is used to replace the diseased aortic tissue. Because the graft is tolerated so well by the body rejection and calcification do not occur. Over time the body deposits its own tissue into the flexible and durable graft.

 

Hypothermic Circulatory Arrest in Surgery

In aortic surgery it is necessary to perform procedures without clamping the aorta, while at the same time keeping the surgical field free of blood. An effective solution was found in hypothermic circulatory arrest (HCA), also called total circulatory arrest (TCA).

Hypothermic circulatory arrest uses very cold body temperatures to temporarily suspend blood flow. Cold temperatures slow cellular activity significantly, and blood circulation can be stopped for up to 40 minutes without harm. This allows surgery to be performed safely on the aorta when clamping to contain blood flow is either impossible or not the preferred approach.

The open anastomosis (surgical connection) technique for ascending aortic dissection surgery is now the favored approach. Using HCA the ascending aorta is not clamped while the aneurysm is surgically removed (resected) and the graft is sewn to the aortic arch.

Aortic Valve, Root, Ascending Aorta and Arch

Aortic disease often involves more than one location. It may simultaneously affect the aortic valve, root, ascending aorta and/or arch. The arteries that branch from these aortic segments require special consideration during surgery. This includes the coronary arteries, which supply blood to the heart, as well as the arteries branching form the arch, which supply blood to the head and upper body. A combination of procedures may be used during surgery.

Aortic Root Reconstruction

The aortic root contains the aortic valve and gives rise to the coronary arteries that supply blood to the heart muscle. There are currently two main valve sparing root operations: the aortic valve reimplantation (David I) and the aortic valve remodeling procedure (David II, Yacoub). There are also several variations of both procedures and are used at VCUMC as appropriate.

Stent Grafts

VCUMC also offers catheter-guided endoluminal stent grafts to repair aortic disease. These stent grafts are inserted through a small incision in the groin and placed in the diseased thoracic aorta. Stent grafts allows faster recovery time and treatment of patients considered too high risk for traditional open aortic surgery.

Options

Aortic surgery may be elective (scheduled) or emergent. Elective surgery is chosen to prevent devastating complications such as aortic valve rupture and tearing. Elective procedures include replacement of the aortic root, reconstruction of the aortic arch, and replacement of a portion or the entire thoracic aorta. Emergency surgery is necessary to repair life-threatening complications of aortic disease. These procedures include repair of aortic dissection, replacement of the aortic valve and repair of a ruptured aneurysm.

Timing of Elective Surgery

Managing aortic disease requires weighing whether the risk of rupture or dissection is greater than the risk of surgery. Improved surgical outcomes allows surgery to be performed earlier today than in the past, operating before life-threatening rupture or dissection occurs. In determining the timing of surgery, the overall condition of the individual and their aortic tissue is evaluated. Factors considered include:

  • Size of aneurysm
  • Shape of aneurysm
  • Rate of expansion
  • Family history of aortic rupture or dissection
  • Type of aortic disease
  • Patient age and general health
  • Symptomatic aorta - pressure or pain in the chest or back